HSAs are highly tax-advantaged savings vehicles that are most attractive to the high income and those with low health service use. They are unlikely to significantly decrease the number of uninsured, who often have low incomes, do not benefit significantly from the tax advantages, nor have assets to cover the large deductibles associated with the plans. Their ability to reduce system wide spending is also limited. HSAs have the potential to increase segmentation of health care risk in private insurance markets, unless employers set premiums to offset the healthier selection or government subsidizes the costs of the remaining comprehensive coverage market.

This report estimates the benefits and costs of alternative forms of state-funded medical reinsurance in Washington using the Urban Institute's Reinsurance Model. A subsidy targeted at all small firms would substantially increase primary coverage but would be very expensive, as most benefit would flow to already insured people. Targeting the conventional small group market by excluding association health plans would reduce state cost per newly uninsured person and would bolster existing regulatory requirements for that sector;s insurers to use modified community rating. Any practical program also needs to identify secure funding and maintain cost consciousness among newly reinsured health plans.

With health reform at the forefront of the national campaign, some charge that proposals to restructure our health care system represent dangerous steps moving the country towards government-run health care and socialized medicine. Similar rhetoric was heard last fall when President Bush vetoed legislation reauthorizing the State Children's Health Insurance Program (SCHIP). We find this rhetoric inapplicable to both the SCHIP bill and proposals from most presidential candidates. The core issues in health reform involve, not the size of government, but proposals' effect on the number of uninsured, access to quality care, cost growth, and consumers' health care choices.

In April 2006, Massachusetts enacted a health care reform bill that seeks to move the state to (almost) universal coverage through a combination of Medicaid expansions, subsidized private health insurance coverage, and insurance reforms. As part of an evaluation of the impacts of the state's reform effort, we conducted surveys of adults aged 18 to 64 years old in Massachusetts in Fall 2006 and Fall 2007. This document provides an overview of the survey approach and the two survey instruments.

Massachusetts's 2006 universal health insurance reform expands Medicaid and uses new sliding-scale subsidies and purchasing mechanisms to make coverage more affordable for individuals and small businesses. Individuals must buy insurance, and employers must offer it or pay a small assessment. How feasible is this approach for the District of Columbia? DC has a relatively small uninsured population, generous publicly sponsored coverage, and an existing eligibility process to administer subsidies. But, its insurance market regulation and total safety net payments for uninsured care are low compared with Massachusetts, creating greater challenges if the District tries to replicate the Massachusetts model.

As efforts to reauthorize the State Children's Health Insurance Program (SCHIP) failed in 2007, Congress settled on a short-term extension of the program. The issues that proved contentious in the SCHIP reauthorization debate will likely be revisited when Congress again takes on SCHIP reauthorization later in 2008 or early 2009 when the extension is set to expire. Instead of seeing the reductions in uninsurance among children that were projected under the vetoed SCHIP reauthorization bills, the number of uninsured children will likely increase, at least in the short run. Without strong growth in public coverage, more children are apt to join the ranks of the uninsured, which increased by 1 million over the past two years.

A longitudinal survey of parents of enrollees in the Los Angeles Healthy Kids Program has found that the program had significant positive impacts on children’s health and access to care. Children experienced improvements in access to and use of ambulatory, specialty and dental care; reduced unmet need; increased parent confidence in getting care and satisfaction with quality; and reduced financial worries. Most important, children’s health status improved, as perceived by parents and according to several measures. Healthy Kids covers uninsured children below 300 percent of poverty who are ineligible for Medicaid or SCHIP, and primarily serves poor, undocumented Latino children.

This issue brief focuses on how employer-sponsored insurance (ESI) coverage has changed among employees. It begins with a brief description of major forces driving ESI: changes in the workforce and the rising costs of health insurance over the four year period. Next, it examines the decline in ESI among employees and the underlying reasons determining whether an employee has ESI, specifically: employer sponsorship of ESI, employee eligibility, employee participation, and employee participation in ESI available through another family member's job. The issue brief concludes by examining how the reasons for the decline in ESI varied across different groups of employees.

The Health Coverage Tax Credit (HCTC), which pays 65 percent of health Insurance premiums for 16,000 trade-displaced workers and others, is the only use of federal income tax credits to cover the otherwise uninsured. In pending legislation to reauthorize Trade Adjustment Assistance, Congress has an opportunity to address HCTC's major problems, including participation by only 15 percent of eligible workers and administrative costs that consume roughly a third of federal spending on the credit. HCTC teaches lessons about how to structure tax credits serving a larger group of uninsured, such as credits proposed by Republican and Democratic Presidential candidates.

In this brief we conclude that, absent a single payer system, it is not possible to achieve universal coverage without an individual mandate. The evidence is strong that voluntary measures alone would leave large numbers of people uninsured. Voluntary measures would tend to enroll disproportionate numbers of individuals with higher cost health problems, creating high premiums and instability in the insurance pools in which they are enrolled, unless further significant government subsidization is provided. The government would also have difficulty redirecting current spending on the uninsured to offset some of the cost associated with a new program without universal coverage.